Provider Demographics
NPI:1093099061
Name:MATLOCK, ERICA Y
Entity Type:Individual
Prefix:
First Name:ERICA
Middle Name:Y
Last Name:MATLOCK
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:606 SHADOW RIDGE DR
Mailing Address - Street 2:
Mailing Address - City:JONESBORO
Mailing Address - State:AR
Mailing Address - Zip Code:72404
Mailing Address - Country:US
Mailing Address - Phone:870-588-1997
Mailing Address - Fax:870-208-8139
Practice Address - Street 1:200 W BROADWAY ST
Practice Address - Street 2:
Practice Address - City:WEST MEMPHIS
Practice Address - State:AR
Practice Address - Zip Code:72301-3904
Practice Address - Country:US
Practice Address - Phone:870-394-7000
Practice Address - Fax:870-394-7001
Is Sole Proprietor?:Yes
Enumeration Date:2011-10-07
Last Update Date:2016-07-28
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
2355S0801X
AR3965235Z00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes235Z00000XSpeech, Language and Hearing Service ProvidersSpeech-Language Pathologist
No2355S0801XSpeech, Language and Hearing Service ProvidersSpecialist/TechnologistSpeech-Language Assistant